EVS representation on a cohesive project team helps ensure contractors have clear expectations for their role in cleanliness.
Image courtesy of UW Medicine/Valley Medical Center
Environmental services (EVS) departments play a crucial role in the health care setting. More than emptying trash or mopping floors, EVS is the first line of defense in breaking the chain of infection.
Most health care facilities, whether they’re hospitals or clinics, struggle with space, leading to never-ending renovations and expansions. EVS leaders find the increased amount of these expansions have a direct impact on the EVS department’s day-to-day operations.
It’s more than the square footage and number of full-time equivalent employees it’s going to take to clean the new area. Considerations must be made from the inception of the design to the ordering and selection of the finishes, flooring and equipment. To manage this process, it’s crucial for EVS leaders to play a key role in project design and construction.
EVS leaders should be sure the needs of EVS have been addressed during the design phase of a project. Did the project team include an EVS closet with floor sink, chemical dispenser, shelving and outlets? Can the space accommodate the many different products EVS departments will be required to support as new technology is adopted? So many things must be considered to allow EVS to function properly in the new area, from lighting to access to electrical outlets. Key areas include the following:
Room design. From ceiling types in the operating room (OR) to the flooring in patient rooms, all design elements need to be reviewed and selected by key stakeholders, including the EVS department. For instance, EVS leaders need to inspect casework and make sure dust ledges don’t have corner pockets that attract dirt and debris, and allow children to stuff papers in them. Similarly, window coverings and frosted glass also affect the department’s ability to perform efficiently.
It also is imperative for EVS leaders to look at the lighting manufacturer’s specs for cleaning, especially in the OR areas. If the lights are being placed on timers, EVS leaders must make sure the project team has reviewed the hours the EVS staff will be working in the area to ensure the EVS team isn’t cleaning in the shadows or the dark.
Technology is continuously being added to patient rooms, ORs and even waiting areas. Electronic kiosks used for checking in, iPads in the patient rooms and many other pieces of technology will need to be wiped down multiple times a day. This requires reviewing the impact to the EVS department’s workflow.
Patient restrooms have a huge impact on EVS teams. In certain areas of the hospital, for instance, they may have whirlpool tubs, requiring proper cleaning of the jets to guarantee microorganisms aren’t left behind for the next patient. Dark grout in the restroom or double-paned windows that are unsealed and dirty on the inside will affect a facility’s Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score. Other elements to be considered in room design include cubical curtains, furniture and even the type of linen used in making the beds.
Flooring. Flooring plays a large role in the healing environment, with selection considerations including colors, patterns, noise reduction and room presentation. EVS leaders must help plan for flooring in entrances, clinics, corridors, emergency departments, ORs, nurses stations, treatment areas, patient rooms and cafeterias, among others.
EVS leaders must make sure they’ve identified the various types of floors within a facility’s design. Reviewing the corresponding flooring spec sheets guarantees proper selection and care of the floor. Whether a project will have brand-new floors or — as is the case with many renovations — a mix of old and new, dirt and bacteria can find their way into corners, doorjambs, cracks and dents, becoming more and more difficult to remove.
Depending on the age of the hospital or clinic, EVS teams may encounter several types of flooring. These include linoleum and vinyl composition tile (VCT), luxury vinyl tile (LVT), bio-based tile and sheet tile flooring made from low-volatile organic compound material, as well as terrazzo in entrances and other public areas.
Identifying high-traffic areas such as corridors and public spaces will influence the type of flooring chosen during design review. In these areas, the flooring must be slip resistant, reasonably easy to clean, durable and long lasting, and available in a variety of textures and colors. It also should be water and stain resistant.
VCT and sheet vinyl have been mainstays in these areas for economic reasons. However, their maintenance needs should be considered by EVS leaders. VCT requires high maintenance and can be labor intensive, with auto-scrubbing, stripping and waxing as part of its routine. Rubber and sheet vinyl are usually flash-coved and easier to maintain.
Terrazzo floors are durable enough to withstand heavy foot traffic, can last for decades and require minimal maintenance. LVT is another sought-after flooring in the care environment. It holds up with rolling loads (e.g., pallet jacks, wheelchairs and patient beds) and is accessible to those with disabilities. Additionally, LVT design choices have evolved to provide a pleasant aesthetic.
When determining the type of flooring to install, it is important for EVS leaders to know that grout is porous by nature unless it is properly sealed. Tile and grout surfaces require more than just the initial sealing. The floors should be evaluated not only after installation, but again after rigorous cleaning.
Grout lines often get darker over time, giving the appearance the floor is dirty even when it is clean. This perception of unsanitary conditions, especially in a patient room or public restrooms, can be reflected in a health care organization’s HCAHPS scores. Additionally, studies have found that some floors in patient rooms are hosts to bacteria, including vancomycin-resistant Enterococci and methicillin-resistant Staphylococcus aureus.
Equipment. Once the design review is completed and approved by all — including EVS leadership — identifying the equipment that will be going in these rooms is critical. Equipment must be identified as remaining in the room (a room fixture) or a mobile piece of equipment to be in the room only while in use.
Not all equipment holds up well to the intense cleaning that is required, sometimes hourly in the case of a pandemic. The manufacturer-recommended cleaning solution will need to be reviewed. This will ensure that the EVS team doesn’t void the warranty on the equipment. There is a chance that the disinfectant required to maintain the equipment isn’t used by a particular organization. In such cases, EVS leaders need to review the process of bringing on this solution. As a key stakeholder, the EVS leader may want to explore the other equipment options, especially if the solution to properly disinfect it isn’t readily available.
If there are no alternatives or the equipment is chosen despite concerns, contacting the manufacturer would be the next step to get a letter authorizing that the disinfectant currently used by EVS won’t void the warranty. EVS leaders likely will need an infection prevention professional’s approval to bring in any new disinfectant, so the EVS team should be prepared to present safety data sheets, dwell times, kill claims and Environmental Protection Agency registration. It also is important to ensure a proper timeline to secure ample supply of the product and training.
Furniture took a real hit with the pandemic and the increased cleaning protocols. In many facilities, day-to-day disinfectant took a toll on wood, plastics and electronic screens. Many screen cleaners had no kill claims, which became problematic for some.
Educating the project team on the need for bleach in C. difficile rooms helps to determine if the equipment will remain in the patient room or be removed after each use. Past the construction phase, it’s important to work with infection prevention professionals and the EVS department manager to designate who will be responsible for cleaning the new equipment.
Beyond participation in formal design and construction processes, EVS leaders also must contend with more chaotic and unpredictable renovation and addition projects, such as revamping areas to add an office or taking down a wall to provide additional patient care services.
These active construction projects are usually on a very short schedule, with no additional time to allow for proper cleaning and disinfecting. In fact, EVS is often the last to know about renovation projects and their timelines. There have been times when an EVS leader will receive a call on a Friday afternoon letting them know that construction work will be done in an area over the weekend that will require a terminal cleaning on Sunday night. Several of these areas are typically serviced Monday through Friday and/or on another shift, leaving the EVS teams scrambling to figure out how to get it done at the last minute.
During renovations and additions, EVS is not only impacted by the final cleaning timeline, but also may become collateral damage to these changes. As square footage is added, the EVS requirements to maintain this new space often are forgotten. Additionally, the design team may demolish an existing EVS closet during the renovation, not realizing the reason it was there in the first place.
Such changes can cause the EVS team to trek across the hospital or clinic to get their carts and supplies. The additional transit time and disruption in workflow has the potential to increase patient wait times for room turnover, which then becomes a patient and staff dissatisfier.
Beyond that, more square footage usually comes with additional restrooms, trash receptacles and beds, creating increased cleaning requests for daily cleaning and room turnovers.
Depending on the size of the renovation or addition, EVS leaders may need to request more resources, including staff and equipment. The staff to properly maintain these areas must be addressed early in the project to allow time for approvals, hiring and training.
Once construction nears completion, EVS leaders must determine who will be conducting the post-construction cleaning. Will it be contracted out, or is the EVS team expected to complete it? If the EVS team is designated to conduct the post-construction cleaning, the information is often relayed late to EVS, creating staffing crunches to complete the work without delay to the project.
This is yet another example of why EVS leaders need to be in the project meetings. They will be able to ensure time has been allotted for EVS to complete the final cleaning and room setup prior to the established go-live date. During construction projects, EVS leaders are rarely asked how much time they need and, consequently, they all have felt the time crunch and pain points of the last-minute scramble.
Hands-on involvement in the construction phase ensures EVS leaders can walk the area to know the time, staff and equipment needed to complete a task. Having early information regarding the expected go-live date gives EVS leaders time to schedule a team versus scrambling to find staff to complete the EVS role. For example, if it’s a patient room, the EVS leader can designate early on who will be moving the bed, overbed table and nightstand, making the whole transition much smoother.
Little things that are needed to fully complete the project prior to the space being ready for occupancy, such as hanging the curtains, stocking paper products and filling soap dispensers, all support the perception of the project as a success. Working through a punch list prior to signing off on the construction project prevents finger pointing later.
The role of EVS in the design and construction process is complex. If nothing else, discussion of the process will cause EVS leaders to pause and reflect on their organizational relationships and how they may build them to become part of these crucial projects.
EVS leaders must get connected so they are invited into design and construction meetings. When listening to those reviewing the upcoming projects, EVS leaders should ask questions: Who’s doing the final cleaning? When are the start and end dates? Who would be the contact for this project? Is there new equipment going in?
The EVS team has an essential role in infection prevention for both pre- and post-built environments. They have the invaluable knowledge, expertise and ability to keep newly built health care spaces clean and safe.
Getting a seat at the PDC table
Developing a great partnership with the facilities department and infection prevention professionals is a key strategy for environmental services (EVS) leaders seeking to advocate for their cause during a planning, design and construction (PDC) project. Sitting down with organizational peers to explain why the EVS department needs to be involved is a sure way to get a seat at the table.
EVS brings value to the PDC table. As discussed in the accompanying article, there are a variety of tasks for which EVS leaders will serve as the gatekeeper and representative. These include, but are not limited to, the identification of unintended warranty violations and potential infectious cross-contamination situations. Many of these issues are identified when the EVS team is given the opportunity to chime in on design features that may create improper cleaning constraints.
The PDC team typically has representatives from the clinical team, administrators, architects, contractors, infection prevention, facilities and, at times, even the doctors working in the affected areas, which gives a cohesive representation of the competing priorities. These priorities include aesthetics, comfort, medical efficiency, infection prevention and cost control. EVS most likely already interacts with these groups on some level, but being part of the PDC decision tree solidifies the needs of EVS being considered.
A cohesive team ensures the group holds the contractors accountable and clear expectations are set regarding their role in cleanliness. For example, having the contractor using walk-off mats outside the containment area prevents construction dust being tracked through the facility, thus allowing EVS to maintain the cleanliness of the facility during construction. Contractors should be informed they are responsible for completing a “construction clean” prior to turning the project over to the facility. The relationship with the contractor and subcontractor is just as important as it is with the rest of the team members.
When EVS is an active participant in the development of the plan, the smallest things having the biggest impact on EVS and the facility can be resolved in an easy and timely manner. One of the greatest results of bringing a multidisciplinary team together is a clear understanding of each other’s priorities. However, EVS leaders shouldn't wait for an invitation; they need to invite themselves. They must be present to advocate for the needs of the EVS department during a PDC meeting, shining a light on the department’s requirements.
Kimberly Miller, CMIP, T-CHEST, CSCT-T, is vice president of support services at UW Medicine/Valley Medical Center in Renton, Wash. She can be contacted via email at Kimberly_Miller@Valleymed.org.